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(1) Background: Multichannel intraluminal impedance–pH (MII-pH) monitoring is commonly used to diagnose gastroesophageal reflux disease (GERD). The mean nocturnal baseline impedance (MNBI) is an important parameter, reflecting the esophageal mucosal integrity and improvement in GERD. This study aims to evaluate the correlation between conventionally measured MNBI and a recently described simple MNBI measurement method in diagnosing pediatric GERD. (2) Methods: This prospective observational study enrolled 64 children aged one month to 18 years who underwent 24 h MII-pH monitoring. Conventional MNBI was measured during stable 10 min intervals at night, while the simple MNBI method averaged impedance throughout the nocturnal supine period. (3) Results: Strong correlations were found between conventional and simple MNBI values across all impedance channels in both infants (r > 0.85) and older children (r > 0.9). Conventional and simple MNBIs in the most distal channel (Z6) effectively differentiated non-erosive reflux disease (NERD) from other phenotypes, with AUCs of 0.864 and 0.860, respectively. The simple MNBI demonstrated good diagnostic performance with similar sensitivity and specificity to the conventional MNBI. (4) Conclusions: Including MNBI measurements into routine MII-pH monitoring may enhance GERD diagnosis and reduce the need for more invasive procedures. [ABSTRACT FROM AUTHOR]

(1) Background: Multichannel intraluminal impedance–pH (MII-pH) monitoring is commonly used to diagnose gastroesophageal reflux disease (GERD). The mean nocturnal baseline impedance (MNBI) is an important parameter, reflecting the esophageal mucosal integrity and improvement in GERD. This study aims to evaluate the correlation between conventionally measured MNBI and a recently described simple MNBI measurement method in diagnosing pediatric GERD. (2) Methods: This prospective observational study enrolled 64 children aged one month to 18 years who underwent 24 h MII-pH monitoring. Conventional MNBI was measured during stable 10 min intervals at night, while the simple MNBI method averaged impedance throughout the nocturnal supine period. (3) Results: Strong correlations were found between conventional and simple MNBI values across all impedance channels in both infants (r > 0.85) and older children (r > 0.9). Conventional and simple MNBIs in the most distal channel (Z6) effectively differentiated non-erosive reflux disease (NERD) from other phenotypes, with AUCs of 0.864 and 0.860, respectively. The simple MNBI demonstrated good diagnostic performance with similar sensitivity and specificity to the conventional MNBI. (4) Conclusions: Including MNBI measurements into routine MII-pH monitoring may enhance GERD diagnosis and reduce the need for more invasive procedures.

Aim: to present data on the role of bile acids in the progression of Barrett's esophagus (BE) and the development of esophageal dysplasia and adenocarcinoma and to provide a rationale for the use of ursodeoxycholic acid in addition to basic therapy in patients with gastroesophageal reflux disease (GERD).Key points. The prevalence of GERD in the world is 13.98 %. In the absence of the necessary treatment or non-compliance with the recommended regimens and duration of drug use, complications of GERD develop such as stricture, bleeding, BE, which, in turn, is a risk factor for the development of esophageal adenocarcinoma (EAC). The basic therapy for GERD is proton pump inhibitors (PPIs), but up to 40 % of patients do not fully respond to PPI monotherapy, which indicates the need to consider, among the factors in the pathogenesis of GERD, the persistence of weakly acidic and weakly alkaline refluxes, the presence of which can be diagnosed by performing 24-hour impedance-pH monitoring. It has been proven that refluxate is predominantly acidic in nature in 50 % of patients with GERD, acidic with a bile component in 39.7 %, and 10.3 % of patients have bile reflux. The weaklly alkaline nature of reflux, due to the presence of duodenal contents, significantly increases the incidence of intestinal metaplasia with dysplasia and EAC compared to acidic pH values. Therefore, stopping duodenal reflux may be an important step in preventing the development of EAC. Among the components of duodenal contents that have a damaging effect on the mucous membrane of the esophagus, the role of bile acids has been most studied. The presence of hydrophobic bile acids, namely deoxycholic acid (DCA), is associated with oxidative DNA damage in lesions of intestinal-type columnar cell metaplasia. Ursodeoxycholic acid (UDCA), a hydrophilic bile acid, is a natural competitive inhibitor of DCA and prevents DNA damage and nuclear factor-κB (NF-κB) activation caused by toxic bile acids in BE epithelial cells. The cytoprotective effect of UDCA, aimed at preventing DNA damage and increasing the reparative capacity of cells in the metaplastic epithelium of the BE, allows us to consider this drug as a means of chemoprophylaxis in patients diagnosed with GERD.Conclusion. The addition of UDCA drugs to the basic therapy is pathogenetically justified in patients with GERD in the presence of duodenogastroesophageal reflux. Prescribing complex therapy will reduce the incidence of esophagitis, progression of BE with the development of dysplasia and adenocarcinoma caused by exposure to bile acids.

Acid reflux has been associated with allograft injury and rejection in lung transplant patients; however, the pathogenic role of non-acid reflux remains debated. We aimed to evaluate the impact of concurrent abnormal non-acid reflux with acid reflux on chronic rejection in lung transplant patients with acid reflux. This was a retrospective cohort study of lung transplant recipients who underwent pre-transplant combined impedance–pH study off acid suppression. Only subjects with acid exposure >4% were included. Non-acid reflux (pH > 4) episodes >27 was considered abnormal per prior normative studies. Chronic rejection was defined as chronic lung allograft dysfunction (CLAD) per International Society for Heart and Lung Transplantation criteria. Time-to-event analyses were performed using Cox proportional hazards and Kaplan–Maier methods, with censoring at death, anti-reflux surgery, or last follow-up. In total, 68 subjects (28 abnormal/40 normal non-acid reflux) met inclusion criteria for the study. Baseline demographic/clinical characteristics were similar between groups. Among this cohort of patients with increased acid exposure, subjects with concurrent abnormal non-acid reflux had significantly higher risk of CLAD than those without on Kaplan–Meier analysis (log-ranked P  = 0.0269). On Cox multivariable regression analysis controlling for body mass index, age at transplantation, and proton pump inhibitor use, concurrent abnormal non-acid reflux remained independently predictive of increased CLAD risk (hazard ratio 2.31, confidence interval: 1.03–5.19, P  = 0.04). Presence of concurrent abnormal non-acid reflux in lung transplant subjects with increased acid exposure is associated with additional risk of chronic rejection. Non-acid reflux may also contribute to pathogenicity in lung allograft injury/rejection, supporting a potential role for impedance-based testing in this population. [ABSTRACT FROM AUTHOR]

Reflux hypersensitivity (RH) is one of the phenotypes of gastroesophageal reflux disease. The latest Rome IV defines RH as a condition with typical reflux symptoms and positive reflux-symptom association despite normal acid exposure. Subsequently, the Lyon consensus proposed detailed cutoff values for the criteria on the basis of experts’ consensus. Rome IV brought a clear-cut perspective into the pathophysiology of gastroesophageal reflux disease and the importance of esophageal hypersensitivity. This perspective can be supported by the fact that other functional gastrointestinal disorders such as irritable bowel syndrome and functional dyspepsia often overlap with RH. Although several possible pathophysiological mechanisms of esophageal hypersensitivity have been identified, there is still unmet medical needs in terms of treatment for this condition. This review summarizes the current knowledge regarding RH.

Background: Impairment of esophageal mucosal integrity as assessed by low mean nocturnal baseline impedance (MNBI) measured in the distal esophagus increases the diagnostic yield of impedance‐pH in patients with inconclusive GERD diagnosis as defined by Lyon criteria. Aim: To assess the diagnostic yield of MNBI measurement in the proximal esophagus, and its relationship with PPI response. Methods: Expert review of off‐therapy impedance‐pH tracings from consecutive patients with heartburn, 80 responders and 80 non‐responders to label‐dose PPI. Data were compared to those from 36 healthy controls using ROC analysis. Multivariate analysis was performed to measure the strength of association of MNBI with PPI response. Results: A threshold value of 2665 Ω was defined for proximal MNBI by ROC analysis, affording 91.7% sensitivity and 86.5% specificity. Proximal and distal MNBI were significantly lower in non‐responder cases as compared to responders. Adding proximal MNBI positivity to pathologic (>6%) acid exposure time (AET) and positive symptom‐reflux association, the proportion of patients with abnormal impedance‐pH findings increased from 74/160 (46%) to 106/160 (66.3%) (p = 0.0016). Among the 12 patients with pathologic proximal MNBI as the only positive impedance‐pH finding, 9 cases (75%) were PPI responders. According to multivariate analysis, AET and pathological distal and proximal MNBI were significantly associated with PPI response, the strongest association observed for proximal MNBI. Conclusions: Impedance baseline assessment in the proximal esophagus may increase the diagnostic yield of impedance‐pH monitoring. Heartburn response to PPI is directly related to ultrastructural mucosal damage in the distal and in the proximal esophagus as well. [ABSTRACT FROM AUTHOR]

Background: On‐therapy impedance‐pH monitoring is recommended in patients with documented GERD and PPI‐refractory heartburn in order to establish whether the unremitting symptom is reflux‐related or not. Aims: To define on‐PPI cut‐offs of impedance‐pH metrics allowing proper interpretation of on‐therapy impedance‐pH monitoring. Methods: Blinded expert review of impedance‐pH tracings performed during double‐dosage PPI, prospectively collected from 150 GERD patients with PPI‐refractory heartburn and 45 GERD patients with PPI‐responsive heartburn but persisting extra‐esophageal symptoms. Acid exposure time (AET), number of total refluxes (TRs), post‐reflux swallow‐induced peristaltic wave (PSPW) index, and mean nocturnal baseline impedance (MNBI) were assessed. On‐PPI cut‐offs were defined and evaluated with ROC analysis and the area under curve (AUC). Results: All the four impedance‐pH metrics significantly differed between PPI‐refractory and PPI‐responsive heartburn cases. At ROC analysis, AUC was 0.73 for AET, 0.75 for TRs, 0.81 for PSPW index, and 0.71 for MNBI; best cut‐offs were ≥1.7% for AET, ≥45 for TRs, ≤36% for PSPW index, and ≤ 1847 Ω for MNBI; AUC of such cut‐offs was 0.66, 0.71, 0.73, and 0.68, respectively. Analysis of PSPW index and MNBI added to assessment of AET and TRs significantly increased the yield of on‐therapy impedance‐pH monitoring in the PPI‐refractory cohort (97% vs. 83%, p < 0.0001). Notably, suboptimal acid suppression as shown by AET ≥1.7% was detected in 43% of 150 PPI‐refractory cases. Conclusions: We have defined on‐PPI cut‐offs of impedance‐pH metrics by which comprehensive assessment of impedance‐pH tracings, including analysis of PSPW index and MNBI can efficiently characterize PPI‐refractory GERD and support treatment escalation. [ABSTRACT FROM AUTHOR]

Background/Aim: Reflux episodes and postreflux swallow‐induced peristaltic wave (PSPW) index are useful impedance parameters that can augment the diagnosis of gastroesophageal reflux disease (GERD). However, manual analysis of pH‐impedance tracings is time consuming, resulting in limited use of these novel impedance metrics. This study aims to evaluate whether a supervised learning artificial intelligence (AI) model is useful to identify reflux episodes and PSPW index. Methods: Consecutive patients underwent 24‐h impedance‐pH monitoring were enrolled for analysis. Multiple AI and machine learning with a deep residual net model for image recognition were explored based on manual interpretation of reflux episodes and PSPW according to criteria from the Wingate Consensus. Intraclass correlation coefficients (ICCs) were used to measure the strength of inter‐rater agreement of data between manual and AI interpretations. Results: We analyzed 106 eligible patients with 7939 impedance events, of whom 38 patients with pathological acid exposure time (AET) and 68 patients with physiological AET. On the manual interpretation, patients with pathological AET had more reflux episodes and lower PSPW index than those with physiological AET. Overall accuracy of AI identification for reflux episodes and PSPW achieved 87% and 82%, respectively. Inter‐rater agreements between AI and manual interpretations achieved excellent for individual numbers of reflux episodes and PSPW index (ICC = 0.965 and ICC = 0.921). Conclusions: AI has the potential to accurately and efficiently measure impedance metrics including reflux episodes and PSPW index. AI can be a reliable adjunct for measuring novel impedance metrics for GERD in the near future. [ABSTRACT FROM AUTHOR]

Novel metrics extracted from pH-impedance monitoring can augment the diagnosis of gastroesophageal reflux disease (GERD). Artificial intelligence (AI) is being widely used to improve the diagnostic capabilities of various diseases. In this review, we update the current literature regarding applications of artificial intelligence in measuring novel pH-impedance metrics. AI demonstrates high performance in the measurement of impedance metrics, including numbers of reflux episodes and post-reflux swallow-induced peristaltic wave index and, furthermore, extracts baseline impedance from the entire pH-impedance study. AI is expected to play a reliable role in facilitating measuring novel impedance metrics in patients with GERD in the near future. [ABSTRACT FROM AUTHOR]

Gastroesophageal reflux disease (GERD) is one of the most common causes of health care seeking at the primary care level in many countries. At an epidemiological level, GERD has been shown to be associated with a number of risk factors: obesity, tobacco smoking, alcohol abuse, certain patterns of eating behaviour, and the use of several medications. GERD is now regarded as a heterogeneous disease and includes different phenotypes (erosive reflux disease, non-erosive reflux disease, hypersensitive oesophagus, functional heartburn), the proper diagnosis of which improves the effectiveness of therapy in patients with heartburn symptoms. Daily impedance–pH monitoring is known to be an integral part of the diagnostic algorithm for GERD and is a functional diagnostic method to record all types of refluxes entering the oesophagus regardless of pH, to assess their association with symptoms, and to determine whether patients with heartburn symptoms belong to a particular phenotype. Esophageal manometry plays a key role in the evaluation of patients with heartburn symptoms, as it helps to rule out other conditions that may mimic GERD: achalasia cardia and scleroderma esophagus. This technique is used to assess thoracic esophageal motility and sphincter function and in the assessment of patients prior to antireflux surgery or in the refractory course of GERD. The article describes in detail GERD risk factors (triggers of heartburn), as well as diagnostic aspects, taking into account a differentiated approach to patients with heartburn based on daily impedance–pH monitoring data in accordance with the current guidelines and recommendations.

Background: Hiatus hernia (HH) contributes to development of gastroesophageal reflux disease, Barrett's esophagus and esophageal adenocarcinoma. This study was aimed to investigate the influence of HH on reflux patterns and distal esophageal mucosal integrity in non‐erosive reflux disease (NERD). Methods: We retrospectively analyzed PPI‐refractory NERD patients referred to three tertiary referral centers who underwent high‐resolution manometry and off‐PPI 24‐h impedance‐pH monitoring (with or without bile spectrophotometry). Patients with HH ≥2 cm (HH group, n = 42) or no HH (non‐HH group, n = 40) with similar esophageal acid exposure time (AET 6%–12%) were included. Key Results: Age, gender, BMI, esophageal motility, AET, and esophageal clearance were similar between the two groups. The HH group had higher numbers of total reflux episodes (p = 0.015) with similar proportion of acid/non‐acid reflux compared with the non‐HH group. Mean nocturnal baseline impedance (MNBI) in the distal esophagus was significantly lower in the HH group than the non‐HH group at both 5 cm (p = 0.002) and 3 cm (p = 0.015) above the lower esophageal sphincter. Multivariable regression analysis showed that HH, less non‐acid reflux and lower post‐reflux swallow‐induced peristaltic wave index (PSPWI) were independently associated with lower MNBI. Among 31 patients tested with bile spectrophotometry, the HH group had significantly longer bile exposure time than the non‐HH group (p = 0.011), and bile reflux inversely and significantly correlated with MNBI (rho = −0.75, p < 0.001). Conclusions and Inferences: Hiatus hernia, less non‐acid reflux and lower PSPWI were associated with lower MNBI. HH impairs distal esophageal mucosal integrity, the mechanism of which we speculate to be through excessive bile reflux. [ABSTRACT FROM AUTHOR]

Summary: Background: A hierarchical approach for gastro‐oesophageal reflux disease (GERD) diagnosis by impedance‐pH monitoring was proposed by the Lyon Consensus, based on acid exposure time (AET) and supportive impedance metrics. Aims: To establish the clinical value of Lyon Consensus criteria in the work‐up of patients with proton pump inhibitory (PPI)‐refractory heartburn. Methods: Expert review of off‐therapy impedance‐pH tracings from unproven GERD patients with PPI‐refractory heartburn prospectively evaluated at referral centers. Impedance metrics, namely total reflux episodes, postreflux swallow‐induced peristaltic wave index, and mean nocturnal baseline impedance, were assessed. Expert review of on‐therapy preoperative impedance‐pH tracings from a separate cohort of surgically treated erosive/nonerosive GERD cases. Results: Off‐therapy, normal, inconclusive, and abnormal AET was found in 59%, 17%, and 23% of 317 cases. Supportive evidence of GERD was provided by abnormal impedance metrics in up to 22% and 62% of cases in the normal and inconclusive AET groups, respectively. Adding the cases with inconclusive AET and abnormal impedance metrics to the abnormal AET group, a significant increase in GERD evidence was observed (from 23% to 37% of cases, p < 0.0002). At the on‐therapy presurgical evaluation, abnormal/inconclusive AET and supraphysiological values of impedance metrics showed ongoing reflux in 21% and 90% of 96 cases, respectively (p < 0.00001); a relationship between on‐therapy ongoing reflux and PPI‐refractory heartburn was confirmed by the favorable surgical outcome at 3‐year follow‐up, 88% of cases being in persistent off‐PPI heartburn remission. Conclusions: Impedance‐pH monitoring, off‐ and on‐therapy, is of high clinical value in the work‐up of patients with PPI‐refractory heartburn. [ABSTRACT FROM AUTHOR]

Novel metrics extracted from pH-impedance monitoring can augment the diagnosis of gastroesophageal reflux disease (GERD). Artificial intelligence (AI) is being widely used to improve the diagnostic capabilities of various diseases. In this review, we update the current literature regarding applications of artificial intelligence in measuring novel pH-impedance metrics. AI demonstrates high performance in the measurement of impedance metrics, including numbers of reflux episodes and post-reflux swallow-induced peristaltic wave index and, furthermore, extracts baseline impedance from the entire pH-impedance study. AI is expected to play a reliable role in facilitating measuring novel impedance metrics in patients with GERD in the near future.

Gastroesophageal reflux disease (GERD) is a widespread disease. Despite the fact that different approaches to the treatment and prevention of recurrence of this disease have been developed, the number of patients with GERD, including refractory form of GERD, is only increasing. To date, well studied and described the possible links of the pathogenesis of this disease, which predetermine certain approaches to the treatment of various variants of GERD. Effective drug therapy of GERD includes the appointment of proton pump inhibitors (PPI). However, doctors are often faced with the problem of ineffective use of PPI in patients with GERD or with the so-called refractory form of GERD. The reasons for the ineffectiveness of therapy of PPI can be associated not only with the pathogenetic features of GERD and therapy, but also with the patient himself. Daily pH monitoring allows to determine the cause of the ineffectiveness of the treatment of PPI if the patient complies with all prescriptions. With ineffective acid suppression in the stomach, it is necessary to increase the dose of PPI or replace it. It is important to prescribe both effective and safe means of correcting the symptoms of GERD, and also take into account the possibility of long-term maintenance of remission when using them. These requirements are met by PPI, created in the form of enantiomers, having an improved pharmacokinetic profile. An example of this differentiated approach is dexlansoprazole, a law-converting monoisomer of lansoprazole with double release technology and the ability to maintain the antisecretory effect for a long time, which appeared relatively recently on the Russian pharmaceutical market. The use of this drug is presented in a clinical case.

Objectives: Esophagogastric junction contractile integral (EGJ‐CI) is a novel indicator to evaluate quantitatively the esophagogastric junction (EGJ) barrier function. We aimed to assess the role of EGJ‐CI in patients with refractory gastroesophageal reflux disease (GERD) symptoms and the correlation between EGJ‐CI and impedance‐pH monitoring characteristics. Methods: In total 82 patients with proton pump inhibitors (PPIs)‐refractory gastroesophageal reflux symptoms (heartburn or regurgitation) were enrolled. These patients were further divided into two groups based on their EGJ‐CI value (39 mmHg·cm). The mean nocturnal baseline impedance (MNBI) was measured to explore its association with EGJ‐CI. Results: The median EGJ‐CI in patients with PPI‐refractory symptoms was 30.8 mmHg·cm. EGJ‐CI was inversely correlated with acid exposure time and reflux episodes; while it was positively correlated with MNBI, distal contractile integral, lower esophageal sphincter basal pressure and integrated relaxation pressure. Patients were further divided into the high (n = 27) and low (n = 55) EGJ‐CI groups using a cut‐off value of 39.0 mmHg·cm. Patients with a low EGJ‐CI had a lower MNBI level than those with a high EGJ‐CI (2703 Ω vs 3545 Ω, P = 0.034). Conclusions: In patients with PPIs‐refractory symptoms, EGJ‐CI is associated with acid exposure and conventional high‐resolution manometry parameters. EGJ‐CI may play an important role in the diagnosis and treatment of patients with refractory GERD. [ABSTRACT FROM AUTHOR]

Aim. The present articleidentifies possible correlations between new parameters for impedance–pH monitoring, such as mean nocturnal baseline impedance (MNBI); post-reflux swallow-induced peristaltic wave index (PSPW); and the main parameter, acid exposure time (AET), as well as esophageal motor function. The authors set out to assess the values of MNBI and the PSPW index as additional criteria improving the diagnostic efficacy of impedance-pH monitoring, the completeness of clinical phenotyping of gastroesophageal reflux disease (GERD), as well as determining the probability of a more severe disease course. Materials and methods. A total of 60 patients aged 19 to 71 (mean age 44.7 years) participated in the study: 30 patients with erosive reflux disease (ERD), 30 with non-erosive reflux disease (NERD) and 20 healthy volunteers aged 26 to 65 (mean age 45.2 years). All of them underwent 24-hour combined esophageal impedance–pH monitoring (Gastroscan-IAM, JSC RPE Istok-Sistema, Fryazino) and high-resolution esophageal manometry using a 22-channel water-perfusion catheter (Solar GI MMS, The Netherlands). The authors studied such parameters as AET, GER number, MNBI level, PSPW index, distal contractile integral (DCI), resting pressure in the lower esophageal sphincter (LES), peristaltic break. Statistical processing was performed using Statistica for Windows 10.0 (StatSoft Inc.) and Prism 8 (GraphPad).Results. The examination of patients revealed that MNBI, the PSPW index and DCI significantly decrease with the development of more severe GERD (r = -0.79; p = 0.0000, r = -0.4; p = 0.0002, r = -0.49; p = 0.0000, respectively). A negative correlation was found between AET and the PSPW index (r = -0.38; p = 0.0003) and the MNBI level (r = -0.59; p = 0.0000). A correlation was determined between the value of MNBI and the following parameters: LES resting pressure (r = 0.26; p = 0.0006), DCI (r = 0.35; p = 0.00004), peristaltic break (r = -0.21; p = 0.007), the PSPW index (r = 0.41; p = 0.0000), and GER number (r = -0.59; p = 0.0). A correlation between the PSPW index and DCI (r = 0.22; p = 0.001) was found as well.In the group of ERD patients, the median values of PSPW and MNBI constitute 0.23 [0.17; 0.33] and 1.13 [0.63; 1.53], respectively. Also, a correlation between AET and the MNBI level was found in this group of patients (r=-0.53; p=0.000036). In turn, MNBI correlated with LES resting pressure (r = 0.46; p = 0.0004), DCI (r = 0.36; p = 0.005), peristaltic break (r = -0.37; p = 0.004), and GER number (r = -0,42; p = 0,0000).In the group of NERD patients, the median values of PSPW and MNBI constitute 0.56 [0.51; 0.75] and 3.3 [2.57; 4.8], respectively. A correlation was also found between the MNBI level and AET (r = -0.35; p = 0.005), GER number (r = -0.39; p = 0.00005), as well as between AET and the PSPW index (r = -0.26; p = 0.0000).In the control group, the median values of PSPW and MNBI constitute 0.42 [0.3; 0.5] and 5.83 [5.21; 6.48], respectively. A statistically significant difference (p = 0.02) was found between the median values of MNBI in patients with ERD, NERD, and the control group. A statistically significant difference (p = 0.0) between the median values of the PSPW index in patients with ERD, NERD and the control group was found as well.Conclusions. The revealed correlations between AET, esophageal motor function and new parameters for impedance-pH monitoring allow them to be used as additional criteria improving the diagnostic efficacy of impedance-pH monitoring and the completeness of GERD clinical phenotyping. A decrease in the level of these parameters in patients reflects the probability of a more severe disease course.

Purpose – to improve the results of surgical treatment of duodenal ulcer due to preoperative diagnosis of concomitant reflux disease and its correction. Before surgery, 46 patients with complicated forms of peptic ulcer disease underwent pH monitoring and 23 – impedance-pH monitoring. Pathological gastroesophageal reflux was found in 58 cases. Before surgery, esophageal pH monitoring was performed in 46 patients with complicated forms of peptic ulcer disease. Against the background of hyper – and normacidity of the stomach in 39 patients pathological acidic gastroesophageal reflux disease with a significant increase of De Meester index was confirmed. Impedance-pH monitoring was performed before surgery in 23 patients with complicated forms of peptic ulcer and concomitant gastroesophageal reflux. Erosive form of gastroesophageal reflux disease was confirmed endoscopically in all patients with hyperacidity (17) and normal acidity (6) of the stomach. In 19 cases pathological gastroesophageal reflux disease was found. In 13 cases the cause of disorders in anti-reflux barrier was a diaphragmatic hernia of I-II degree. Gastroesophageal reflux disease was caused by increased intragastric pressure due to ulcer stenosis in 6 patients. pH- monitoring in patients with acidic gastroesophageal reflux allows to establish a pathological or physiological reflux. Conducting impedance-pH monitoring allows to determine the number of reflux episodes and their qualitative characteristics (acidic or alkaline; liquid, gas or mixed), as well as to determine the indications for a differentiated approach in the treatment of gastroesophageal reflux.

Introduction: Increased nonacid reflux is diagnosed in a subgroup of patients with gastroesophageal reflux disease who often present with reflux symptoms refractory to proton-pump inhibitor therapy. Despite the prevalence of this condition, the management approach for patients with increased nonacid reflux can often be varied and unclear. Aims: Our primary aim was to investigate physician management patterns for patients who had received a diagnosis of increased nonacid reflux on impedance-pH studies. Methods: Reflux studies in patients with increased nonacid reflux per Lyon Consensus criteria and management approaches were retrospectively reviewed. Reflux symptom survey, manometry findings, reflux symptom association (RSA) on reflux testing, immediate posttesting management information, and managing provider information were assessed. Results: A total of 43 subjects in total were analyzed. Management plan after a diagnosis of increased nonacid reflux was decided by a gastroenterologist in over 95% of cases and varied greatly with no changes being the most common. Even among subjects with + RSA on reflux monitoring, no change in management was the most common action, although this occurred much less frequently compared to subjects with − RSA (28.6% vs. 78.6%, p < 0.01). When change in therapy occurred, medical treatment with baclofen was the most common choice (21.4%). Other management changes included medications for visceral hypersensitivity and antireflux surgery, although these changes occurred rarely. Conclusions: Abnormally increased nonacid reflux is frequently encountered on impedance-pH studies; however, management decisions vary significantly among gastroenterologists. When treatment change is implemented, they are variable and can include lifestyle modifications, medication trials, or antireflux surgery. Future development of standardized management algorithms for increased nonacid reflux is needed. [ABSTRACT FROM AUTHOR]

This work summarizes new and emerging metrics and tools in esophageal function testing and their potential clinical impact. Because the diagnostic sensitivity and reliability of conventional impedance‐pH variables are suboptimal, several novel impedance parameters, such as the postreflux swallow–induced peristaltic wave index and the mean nocturnal baseline impedance, as well as mucosal impedance, are entering a validation stage prior to general clinical use. The accurate diagnosis of behavioral disorders in patients with rumination syndrome and supragastric belching using ambulatory multiple intraluminal impedance‐pH can lead directly to behavioral interventions in patients with refractory gastroesophageal reflux disease (GERD). New provocative measures, such as multiple rapid swallows and the rapid drink challenge, have been developed to overcome the limitations of standard high‐resolution esophageal manometry, aiming at further clarifying esophageal dysmotility. Furthermore, the current diagnostic and therapeutic challenges in patients with esophageal involvement in Sjogren's syndrome and scleroderma, who tend to have severe forms of GERD, are entering a new investigative and clinical phase. [ABSTRACT FROM AUTHOR]

Background: Supragastric belching (SGB) may play a role in the pathophysiology of proton pump inhibitors (PPIs)-refractoriness in gastroesophageal reflux disease (GERD). SGB may be present in up to 40% of reflux symptoms in PPI-refractory GERD. Most reports on SGB have come from Western countries, and little is known about the prevalence and relevance of SGB in Asian refractory GERD patients. This study aimed at comparing the role of SGB in GERD patients in Japan and the UK.Methods: We re-analyzed impedance-pH monitoring tracings from patients who were referred to tertiary centers in Japan and the UK due to PPI-refractory reflux symptoms. The prevalence of excessive SGB and the impact of SGB on reflux symptoms were compared between the two countries.Results: Impedance-pH tracings from124 Japanese and 83 British patients were re-analyzed. Japanese patients were significantly younger and had smaller body mass index than the British (P < 0.001). Japanese patients had significantly lower prevalence of excessive SGB (18.5%) than the UK (36.1%) irrespective of reflux phenotype (P = 0.006). Logistic regression analysis showed that the geographical/cultural difference was the only factor associated with the different prevalence of SGB (odds ratio; 2.91, 95% CI 1.09-7.73, P = 0.032). SGB were related to typical reflux symptoms very rarely in Japan [0% (0-4.9)] compared to the UK [35% (0-54.1)] (P = 0.071).Conclusions: The prevalence of SGB and their impact on reflux symptoms is significantly lower in Japan compared to the UK. The difference is not related to reflux parameters but might come from ethnic/cultural factors to be further characterized. [ABSTRACT FROM AUTHOR]

Gastro-esophageal reflux disease (GERD) is a highly prevalent, chronic, relapsing disorder, whose knowledge has increased in last years thanks to the advent of new sophisticated techniques, such as 24-h impedance-pH monitoring and high-resolution manometry, for the study of esophageal functions. This review provides an overview of our advancements in understanding the complex pathophysiology, improving the diagnosis and defining the modern pharmacological therapeutic approach to GERD. The growing clinical application of impedance-pH testing has allowed us to know the diversity of patients with non-erosive reflux disease (NERD), who nowadays represent about 70% of the whole population with reflux symptoms. We have realized that NERD has to be considered as an umbrella term covering various subgroups with different pathophysiologies. The development of new impedance metrics, in particular mean nocturnal baseline impedance, seems to be promising in the improvement of the diagnostic process of this disease. There are no particularly innovative features in the pharmacological therapy of GERD, unless the interest toward drugs is able to increase the defense properties of esophageal mucosa and/or its protection. These compounds can be of help in combination with proton pump inhibitors in NERD patients with partial response to antisecretory drugs alone. [ABSTRACT FROM AUTHOR]

Background/Aim: We evaluated the efficacy of vonoprazan (VPZ), a novel potassium-competitive acid blocker, in patients with proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease (GERD), exhibiting continued pathological esophageal acid exposure (EAE). Methods: Despite ≥8 weeks of appropriate PPI therapy, patients with -persistent reflux symptoms and pathological EAE times (EAETs ≥4%) were invited to switch to VPZ treatment. After an 8-week-course of once-daily VPZ (20 mg), multichannel intraluminal impedance-pH (MII-pH) monitoring was repeated to compare gastric acid exposure times (GAETs), EAETs, and other reflux parameters relative to the baseline values. Before each MII-pH study, reflux symptom severities were scored using the Gastrointestinal Symptom Rating Scale; erosive esophagitis and fasting plasma gastrin levels were also assessed. Results: From among the 124 patients undergoing MII-pH monitoring, 13 patients (median age, 69 years; females, 64%) were monitored at baseline (while on PPI therapy) and after VPZ therapy. The median GAET associated with VPZ treatment (23.8%) was less than that for PPI treatment (41.1%; p = 0.01), including both daytime and nighttime measurements. VPZ therapy resulted in better median EAET values (4.5%) than did PPI therapy (10.6%) during the 24-h monitoring period (p = 0.055). EAE normalization was achieved in 46% of VPZ-treated patients and was associated with complete gastric acid suppression (p = 0.005). After switching to VPZ, reflux symptoms (p < 0.01) and erosive esophagitis (p = 0.01) improved. Conclusion: In patients with PPI-refractory GERD, VPZ provides more potent gastric acid suppression, more effective EAE control, enhanced symptom improvement, and better esophagitis healing than PPIs. [ABSTRACT FROM AUTHOR]

Reflux hypersensitivity (RH) is one of the phenotypes of gastroesophageal reflux disease. The latest Rome IV defines RH as a condition with typical reflux symptoms and positive reflux-symptom association despite normal acid exposure. Subsequently, the Lyon consensus proposed detailed cutoff values for the criteria on the basis of experts' consensus. Rome IV brought a clear-cut perspective into the pathophysiology of gastroesophageal reflux disease and the importance of esophageal hypersensitivity. This perspective can be supported by the fact that other functional gastrointestinal disorders such as irritable bowel syndrome and functional dyspepsia often overlap with RH. Although several possible pathophysiological mechanisms of esophageal hypersensitivity have been identified, there is still unmet medical needs in terms of treatment for this condition. This review summarizes the current knowledge regarding RH.

Background: The present study examined the pathogenesis of potassium-competitive acid blocker (P-CAB)-resistant non-erosive reflux disease (NERD). Methods: Forty-three patients with NERD, who had persistent reflux symptoms despite the administration of P-CAB, were included in this study. After excluding eosinophilic esophagitis and primary esophageal motility disorders, esophageal impedance-pH monitoring was performed. In symptom index (SI)-positive patients, the mechanism of SI-positivity and percent time with intragastric pH > 4 and with esophageal pH < 4 were investigated according to the presence or absence of Helicobacter pylori infection. Results: One (2.3%) of 43 patients had a primary esophageal motility disorder (Jackhammer esophagus). Eighteen (41.9%) and 3 (7%) patients were SI-positive for liquid and gas-only reflux, respectively, and the remaining 21 patients who were SI-negative (48.8%) had functional heartburn. All patients SI-positive for liquid reflux were SI-positive for weakly acidic reflux. Gastric acid was sufficiently suppressed by P-CAB, regardless of the presence or absence of H. pylori infection. Conclusions: The pathogenesis of -P-CAB-resistant NERD was elucidated in 51% of patients. Symptoms in all patients SI-positive for liquid reflux were related to weakly acidic reflux, and symptoms related to acid reflux may be ruled out by the administration of P-CAB. [ABSTRACT FROM AUTHOR]

Purpose – to improve the results of surgical treatment of duodenal ulcer due to preoperative diagnosis of concomitant reflux disease and its correction. Before surgery, 46 patients with complicated forms of peptic ulcer disease underwent pH monitoring and 23 – impedance-pH monitoring. Pathological gastroesophageal reflux was found in 58 cases. Before surgery, esophageal pH monitoring was performed in 46 patients with complicated forms of peptic ulcer disease. Against the background of hyper – and normacidity of the stomach in 39 patients pathological acidic gastroesophageal reflux disease with a significant increase of De Meester index was confirmed. Impedance-pH monitoring was performed before surgery in 23 patients with complicated forms of peptic ulcer and concomitant gastroesophageal reflux. Erosive form of gastroesophageal reflux disease was confirmed endoscopically in all patients with hyperacidity (17) and normal acidity (6) of the stomach. In 19 cases pathological gastroesophageal reflux disease was found. In 13 cases the cause of disorders in anti-reflux barrier was a diaphragmatic hernia of I-II degree. Gastroesophageal reflux disease was caused by increased intragastric pressure due to ulcer stenosis in 6 patients. pHmonitoring in patients with acidic gastroesophageal reflux allows to establish a pathological or physiological reflux. Conducting impedance-pH monitoring allows to determine the number of reflux episodes and their qualitative characteristics (acidic or alkaline; liquid, gas or mixed), as well as to determine the indications for a differentiated approach in the treatment of gastroesophageal reflux. [ABSTRACT FROM AUTHOR]

Introduction Distal esophageal baseline impedance (BI) levels reflect the esophageal mucosal integrity in reflux disease. Systemic sclerosis (SSc) could potentially affect the integrity of esophageal mucosa and consequently impair distal and proximal BI levels, but data in this regard are lacking. Aim and methods We aimed to prospectively investigate and compare BI levels among non-erosive reflux disease (NERD), SSc patients, and healthy controls (HCs). Consecutive patients with reflux symptoms and well-defined diagnosis of SSc underwent upper endoscopy and, in case of no lesions encountered, manometry and impedance-pH testing off-therapy. In addition to traditional impedance-pH parameters, BI values at 3, 5, 7, and 17 cm above the lower esophageal sphincter were calculated. Results Fifty-two patients with NERD, 50 with SSc, and 50 HCs were enrolled. Nineteen (38%) SSc patients and 22 (42%) NERD patients had abnormal acid exposure. In patients with SSc, median BI values were significantly lower than in NERD patients and HCs ( p < 0.0001) at 3, 5, and 7 cm; there was no difference between HCs and NERD patients at 17 cm in the proximal esophagus, whereas a significant difference was observed at 17 cm between SSc and NERD as well as HCs ( p < 0.01). Conclusion Distal and proximal BI values in SSc patients were lower than in NERD and HCs, thus we speculated that these findings may be related to the deposition of collagen in the connective tissue. Measurement of BI may be used as an indirect, but simple and accurate marker of esophageal involvement in patients with SSc. [ABSTRACT FROM AUTHOR]

The Rome IV Committee introduced a major change in the classification of functional gastrointestinal disorders, proposing a more restrictive definition of gastroesophageal reflux disease (GERD). It was suggested that hypersensitive esophagus (HE) may sit more firmly within the functional realm. It was suggested that GERD diagnosis should be based upon abnormal acid exposure time (AET) only, implying no advantage of impedance-pH over pH monitoring. Symptom association probability (SAP), symptom index (SI) and heartburn relief with proton pump inhibitor (PPI) therapy were regarded as unreliable, whereas a lack of response to PPI was considered as evidence of functional heartburn. These assumptions are contradicted by numerous studies showing the clinical relevance of weakly acidic refluxes and the diagnostic utility of SAP, SI and new impedance parameters, namely the post-reflux swallow-induced peristaltic wave (PSPW) index and the mean nocturnal baseline impedance (MNBI). The PSPW index and MNBI provide significant diagnostic advantage, particularly in patients with normal AET who can be classified as HE when both parameters are abnormal, even though SAP and SI are negative. Visceral pain modulators are recommended by the Rome IV Committee despite scanty evidence of efficacy, but a positive outcome with medical or surgical anti-reflux treatment has been reported by several studies of HE patients. Therefore, we believe that patients with endoscopy-negative heartburn should be investigated by means of impedance-pH monitoring with analysis of PSPW index and MNBI: such an approach provides accurate identification of HE cases, who remain, in our opinion, within the realm of GERD and should be treated accordingly. [ABSTRACT FROM AUTHOR]

In the past, the attention of physiologists and doctors has been mainly focused on the key role of acid in the pathogenesis of gastroesophageal reflux disease (GERD), but increasing evidence that 20-40% of reflux patients respond not at all or only partially to proton pump inhibitors (PPIs) has underlined the concept that factors other than acid are implicated in its development and the elicitation of symptoms. Among these, impaired mucosal integrity, particularly in most patients with non-erosive reflux disease, has recently been reincluded and the reinforcement of defensive mechanisms and/or its protection has been reappointed as a renewed therapeutic target for the management of GERD patients. In this review we will summarize the existing knowledge of the old and novel compounds able to produce this therapeutic effect, including sucralfate, alginate-based drugs, and a new medical device consisting of hyaluronic acid and chondroitin sulfate dispersed in a bioadhesive carrier, together with the potential indications for their use. It is to be stressed, however, that, although these compounds may represent a real alternative to PPI therapy in GERD, the combination of mucosal protection with acid suppression may help manage many cases with a partial or unsatisfactory response to PPIs alone. [ABSTRACT FROM AUTHOR]

Heartburn is the most specific symptom of gastroesophageal reflux disease (GERD). In clinical practice, heartburn relief by a proton pump inhibitor (PPI) trial does suffice to confirm GERD. However, an objective diagnosis of GERD is required before anti-reflux endoscopic or surgical interventions, independently from PPI response. Thus, since normal findings at upper endoscopy are detected in the majority of patients with heartburn, reflux monitoring is often required. When traditional catheter-based or wireless pH tests are used, reflux episodes are conventionally identified by pH drops below 4.0 units. Combined impedance-pH monitoring has the advantage to provide a comprehensive assessment of both physical and chemical properties of refluxate and the distinction between acid and weakly acidic refluxes, both proven to cause heartburn. Unfortunately, the conventional impedance-pH parameters, namely acid exposure time and number of reflux events, are characterized by suboptimal diagnostic sensitivity, and the reliability of symptom-reflux association indexes remains questionable. Therefore, novel impedance parameters, namely the post-reflux swallow-induced peristaltic wave (PSPW) index and the mean nocturnal baseline impedance (MNBI), have recently been proposed in order to achieve a better diagnostic yield. In fact, they proved to be highly accurate in distinguishing reflux-related from reflux-unrelated heartburn, off- as well as on-PPI therapy. Currently, manual review of impedance-pH tracings is needed because of the modest accuracy of available software tools for automated analysis. PSPW index and MNBI are highly applicable and reproducible, and their calculation requires a few additional minutes during the manual review of impedance-pH tracings. So far, we believe that PSPW index and MNBI are ready for prime time and should become part of the standard analysis of impedance-pH tracings for GERD diagnosis in patients with endoscopy-negative heartburn. [ABSTRACT FROM AUTHOR]

Background: Various mechanisms have been suggested to be responsible for contributing to the occurrence of proton pump inhibitor (PPI)-resistant non-erosive reflux disease (NERD). The aims of this study were to clarify the pathogenesis of PPI-resistant NERD. Methods: Fifty-three patients with NERD, who had persistent reflux symptoms despite taking double-dose PPI, were included in this study. After excluding eosinophilic esophagitis (EoE) and primary esophageal motility disorder, esophageal impedance-pH monitoring was carried out. In symptom index (SI)-positive patients, the mechanism of SI positivity and the percent time with intragastric pH >4 were investigated according to the presence or absence of Helicobacter pylori infection. Results: One of the 53 patients had EoE, and 4 had primary esophageal motility disorder. Twenty-three and 2 patients were SI-positive for liquid and gas-only reflux respectively. Of 17 SI-positive, H. pylori-negative patients, 5 were SI-positive for acid reflux, whereas all of the H. pylori-positive patients were SI-positive for non-acid reflux. The percent time with intragastric pH >4 was significantly lower in the H. pylori-negative patients than in the H. pylori-positive patients. Conclusions: The pathogenesis of double-dose PPI-resistant NERD was identified in 57%. In some of H. pylori-negative patients, acid-related symptoms were observed. However, in H. pylori-positive patients, these symptoms were excluded by taking double-dose PPI. [ABSTRACT FROM AUTHOR]

Background On-therapy impedance- pH monitoring in proton pump inhibitor ( PPI)-refractory gastroesophageal reflux disease ( GERD) yielded conflicting results. We aimed to assess the diagnostic value of postreflux swallow-induced peristaltic wave ( PSPW) index and mean nocturnal baseline impedance ( MNBI) in PPI-refractory heartburn. Methods On-therapy impedance- pH tracings from 189 consecutive patients with PPI-refractory heartburn were blindly reviewed. Patients were subdivided into refractory reflux esophagitis ( RRE), healed reflux esophagitis ( HRE), non-erosive reflux disease ( NERD), and functional heartburn ( FH) according to endoscopic and conventional impedance- pH findings. The diagnostic accuracy of PSPW index and MNBI in separating NERD from FH was assessed with receiver-operating-characteristic ( ROC) analysis. Objectively documented persistent reflux remission at 3-year follow-up in 53 patients who underwent laparoscopic fundoplication served to evaluate PSPW index and MNBI as independent predictors of PPI-refractory GERD confirmed by positive surgical outcome. Key Results Median PSPW index and MNBI values were significantly lower in 39 RRE (16%; 1145 Ω) than in 41 HRE (25%; 1741 Ω) and in 68 NERD (29%; 2374 Ω) patients, and in all three GERD subgroups compared to 41 FH cases (67%; 3488 Ω) ( P<.008). At ROC analysis, comparing NERD to FH the area under the curve was 0.886 with PSPW index and 0.677 with MNBI ( P=.005). PSPW index was an independent predictor of PPI-refractory GERD (odds ratio 0.6983, P=.012). Conclusions & Inferences At on-therapy impedance- pH monitoring, PSPW index and MNBI efficiently distinguish PPI-refractory NERD from FH. The PSPW index represents an independent predictor of PPI-refractory GERD. [ABSTRACT FROM AUTHOR]

The aim of this study was to assess the association between chronic cough and acid or weakly acid gastroesophageal reflux (GER) determined by 24-hour multichannel intraluminal impedance-pH monitoring and to assess whether the association is age dependent. Overall 150 children (mean age 7.5 years; range 0.3-18.0 years; male/female 90/60) were enrolled. Median of 87.5% (0% to 100%) of all cough episodes were associated with reflux; 9% (0% to 100%) with acidic and 60% (0% to 100%) with weakly acidic episodes. In 52 children (34.7%), all cough episodes were associated with GER (100% association). Children younger than 2 years had significantly higher number of cough episodes associated with total (P = .03) and weakly acidic GER (P = .01). Binary logistic regression confirmed that only increase in age decreases the risk for complete (100%) association between cough episode and GER. Cough is significantly associated with weakly acidic GER and children of younger age are at higher risk. [ABSTRACT FROM AUTHOR]

Background Approximately one-third of gastroesophageal reflux disease ( GERD) patients have symptoms resistant to proton pump inhibitor ( PPI). We used the high-resolution manometry ( HRM) and multichannel intraluminal impedance-pH ( MII-pH) monitoring to investigate potential predictors of PPI failure in non-erosive reflux disease ( NERD) patients. Methods One hundred and seventeen NERD patients were included, within which there were 44 PPI failure patients. The symptomatic questionnaire GerdQ, HRM and 24-hour MII-pH monitoring were performed before PPI therapy. PPI failure was defined as persistent reflux symptoms for more than 1 day during the last week on esomeprazole (20 mg twice daily) for continuous 4 weeks. The predictors for PPI failure were investigated by multivariable logistic regression analysis. Key Results Proton pump inhibitor failure patients had lower body mass index ( BMI) and more concomitant functional dyspepsia ( FD) symptoms. PPI failure patients had a higher percentage of type I esophagogastric junction ( EGJ) morphology ( p = 0.005), increased EGJ augmentation ( p = 0.000), higher prevalence of esophageal motility disorders ( p = 0.005) and a higher ratio of negative symptom index ( SI, p = 0.000). Multivariable regression analysis showed that concomitance of FD symptoms, EGJ augmentation and negative SI were independent risk factors for PPI failure in NERD. Conclusions & Inferences Approximately half of PPI failure patients were found to have esophageal motility disorders in HRM. The independent risk factors for PPI failure in NERD were concomitant FD symptoms, increased EGJ augmentation and negative SI. [ABSTRACT FROM AUTHOR]

Background: The addition of impedance to 24-h pH monitoring has allowed detection of weakly acidic reflux, but the extent to which pH-impedance (pH-MII) monitoring improves outcomes is unknown.Methods: This was a prospective observational study. Patients referred for pH or pH-MII monitoring completed a standardized questionnaire on improvement in the dominant symptom, their satisfaction, and treatment at 3 and 12 months after the test during a telephone interview.Results: A total of 184 patients (mean age, 52 years, range, 19-82 years; 35 % with typical symptoms; and 89 % tested off therapy) completed pH (n = 92) or pH-MII monitoring (n = 92) over a period of 15 months. The two arms were similar in terms of demographic, clinical, and endoscopic variables. Ten patients in the pH-MII arm showed evidence of weakly acidic reflux disease. There was no difference in the percentage of patients in the pH and pH-MII monitoring arms who experienced improvement in their dominant symptom after 3 (58 vs. 63 %; p = 0.621) or 12 months (66 vs. 70 %; p = 0.234), and the same was true for patient satisfaction. There were also no between-group difference in the use of proton pump inhibitors (PPIs) after 3 (63 vs. 68.5 %; p = 0.437) or 12 months (47 vs. 60.5 %; p = 0.051). PPIs were prescribed more frequently after a positive test (p < 0.001) although they were used by 45.6 % of the negative patients. Only one patient underwent fundoplication.Conclusions: Two-thirds of patients undergoing pH-MII monitoring experience a positive outcome, similarly to what occurs after traditional pH monitoring. Physicians often pay little attention to the test results, especially if they are negative. [ABSTRACT FROM AUTHOR]

Background The role of esophagogastric junction contractile integral ( EGJ- CI) as assessed by high-resolution manometry ( HRM) is unclear. We aimed to correlate the EGJ- CI with impedance-pH findings in gastro-esophageal reflux disease ( GERD) patients. Methods Consecutive patients with GERD symptoms were enrolled. All patients underwent upper endoscopy, HRM, and impedance-pH testing. The EGJ- CI was calculated using the distal contractile integral tool box during three consecutive respiratory cycles. The value was then divided by the duration of these cycles. A value below 13 was considered as a defective EGJ- CI. We also assessed EGJ morphology, esophageal acid exposure time ( AET), number of reflux episodes ( NRE), and symptom association analysis ( SAA). A positive impedance-pH monitoring was considered in case of abnormal AET and/or NRE and/or positive SAA. Key Results Among 130 patients we enrolled, 91 had GERD (abnormal AET and/or elevated NRE and/or positive SAA) and 39 had functional heartburn ( FH) (negative endoscopy, normal AET, normal NRE, and negative SAA). The GERD patients had a lower median value of EGJ- CI (11 [3.1-20.7] vs 22 [9.9-41], p < 0.02) compared to FH patients. Patients with a defective EGJ- CI had, more frequently, a positive impedance-pH monitoring or esophageal mucosal lesions at endoscopy ( p < 0.05 and p < 0.05, respectively) than patients with a normal EGJ- CI. An EGJ- CI cut-off value of 5 mmHg cm yielded the optimal performance in identifying GERD at impedance-pH (sensitivity 89%-specificity 63%). Conclusions & Inferences A defective EGJ- CI at HRM is clearly associated with evidence of GERD at impedance-pH monitoring. Evaluating EGJ- CI may be useful to predict an abnormal impedance-pH testing. [ABSTRACT FROM AUTHOR]

Background: The detection of gastroesophageal reflux (GERD) via pH testing is the key component of the evaluation of patients considered for antireflux surgery. Two common pH testing systems exist, a multichannel, intraluminal impedance-pH monitoring (MII-pH) catheter, and wireless (Bravo) capsule; however, discrepancies between the two systems exist. In patients with atypical symptoms, MII-pH catheter is often used preferentially. We aimed to elucidate the magnitude of this discrepancy and to assess the diagnostic value of MII-pH and the Bravo wireless capsule in a population of patients with mixed respiratory and typical symptoms. Methods: The study population consisted of 66 patients tested with MII-pH and Bravo pH testing within 90 days between July 2009 and 2013. All patients presented with laryngo-pharyngo-respiratory (LPR) symptoms. Patient demographics, symptomatology, manometric and endoscopic findings, and pH monitoring parameters were analyzed. Patients were divided into four comparison groups: both pH tests positive, MII-pH negative/Bravo positive, MII-pH positive/Bravo negative, and both pH tests negative. Results: Nearly half of the patients (44 %) had discordant pH test results. Of these, 90 % (26/29) had a negative MII-pH but positive Bravo study. In this group, the difference in the DeMeester score was large, a median of 29.3. These patients had a higher BMI (28.5 vs. 26.1, p = 0.0357), were more likely to complain of heartburn (50 vs. 23 %, p = 0.0110), to have a hiatal hernia, (85 vs. 53 %, p = 0.0075) and a structurally defective lower esophageal sphincter (LES, 85 vs. 58 %, p = 0.0208). Conclusions: In patients with LPR symptoms, we found a high prevalence of discordant esophageal pH results, most commonly a negative MII-pH catheter and positive Bravo. As these patients exhibited characteristics consistent with GERD (heartburn, defective LES, hiatal hernia), the Bravo results are likely true. A 24-h MII-pH catheter study may be inadequate to diagnose GERD in this patient population. [ABSTRACT FROM AUTHOR]

Introduction: The management of laryngopharyngeal reflux (LPR) has been challenging. Hypopharyngeal multichannel intraluminal impedance (HMII) has shown to increase the sensitivity in diagnosing LPR. The objective of this study is to investigate the potential use of pepsin and Sep70 as diagnostic tools for detection of LPR in combination with HMII. Materials and methods: Tissue samples of hypopharynx, distal esophagus, and gastric cardia were collected from patients with LPR symptoms regardless of gastroesophageal reflux (GERD) diagnosis and underwent HMII to detect LPR and high esophageal reflux (HER: reflux 2 cm distal to upper esophageal sphincter) events. Patients were classified into two groups based on the presence of abnormal proximal exposure (APE), which was defined as LPR ≥1/day and/or HER ≥5/day: (1) positive-APE and (2) negative-APE. Patients with typical GERD symptoms without LPR symptoms who did not undergo HMII were used as a 'control' GERD group. Protein was isolated from tissue samples and Western blot analysis of pepsin and Sep70 was performed. Pepsinogen was used as a control to differentiate pepsin from pepsinogen. Relative quantitation was performed using Image Studio Lite Software with normalization against the internal actin of each blot. Results: From October 2012 to September 2013, 55 patients underwent HMII. Of 55, 20 patients underwent biopsies from hypopharynx (17 positive-APE and 3 negative-APE). Ten patients with typical GERD symptoms were identified from tissue bank as a 'control' GERD group. Pepsin was detected in distal esophagus and hypopharynx in all groups without significant difference among groups. However, Sep70 in distal esophagus and hypopharynx was significantly depleted in the positive-APE group compared to the other groups ( p = 0.032 and 0.002, respectively). Conclusion: Depletion of Sep70 with the presence of pepsin in the hypopharynx may indicate cellular injury in laryngopharynx due to constant proximal reflux. However, the normative data for these markers have to be validated. [ABSTRACT FROM AUTHOR]